The impact of body image on physical and mental health

Response to the call for evidence by the Health and Social Care
Committee

Executive summary

 The body image can be defined as the conscious awareness of one’s body. It is
multifaceted and one driver of health-related behaviours. Body image distortions
characterise eating and body dysmorphic disorders.
 Research suggests that there is a strong reciprocal relationship between body
image and both physical and mental health.
 Body image concerns / body dissatisfaction are associated with low self-esteem
and low mental health and are predictive of eating and body dysmorphic
disorders. This is especially true for those who internalise certain body ideals.
 Body image concerns drive people to make behavioural choices that impact their
physical health (i.e. dieting, exercising). This can help with body image concerns
but can also lead to physical ill health and psychopathologies.
 Excessive focus on patient weight, the reinforcement of the thin / muscular body
ideal and the stigmatisation of obesity have unintended negative consequences
on the physical and mental health of patients, both directly and indirectly by
reducing patient engagement with healthcare services.
 Minor cosmetic procedures may improve body image and protect against self-
harming behaviours; however, surgical procedures rarely improve body image in
those with body dysmorphic disorder.

 The following recommendations are made:

o To improve knowledge of unintended consequences of reinforcing certain
body ideals and stigmatisation of those outside this ideal on mental and
physical health, both within healthcare settings and wider society
o To improve framing of health-related messaging because health is not best
characterised by weight or appearance
o Good health campaigns should be weight-neutral but promote positive
self-care and cardiovascular fitness
o To improve the balance of research funding toward (i) evidence-based
programmes that optimally improve mental and physical health and (ii)
media literacy interventions and tackling appearance-related bullying
especially in those at risk
o To enlist cosmetic surgery providers in screening of persons at risk of body
dysmorphic disorder and referral to psychological services that may better
serve them

Introduction

Dr Helge Gillmeister is a Reader at the Department of Psychology, University of Essex

in Colchester, UK. Her research expertise concerns body and self-awareness, which she
examines with behavioural and brain imaging methods in adults with and without clinical
symptoms of depersonalisation, eating and body dysmorphic disorders. She has been
involved in several projects related to physical activity, weight stigma, mental health and
body image across the life span. She is a board member of the British Association for
Cognitive Neuroscience (BACN) for whom she acts as a membership secretary; she is
also a member of the Experimental Psychology Society (EPS), European Brain and
Behaviour Society (EBBS), and the European Society for Cognitive and Affective
Neuroscience (ESCAN). She is a UK Science Media Centre database expert on body
image and a fellow of the Higher Education Academy. For more information please see
Website: https://www.essex.ac.uk/people/GILLM41709
ORCID: https://orcid.org/0000-0001-5999-5303

The written evidence below is submitted in Dr Gillmeister’s personal capacity as expert in

the field of body image, mental health and physical activity, and is based on her own
research, reading and broader understanding of the topic.

Responses

 What is the relationship between people’s perception of their body image

and their physical and mental health?

1) My answer to this question is based on two premises, which are well founded within
psychological and cognitive neuroscience research:

i) Two broad types of mental representations of the body can be distinguished:

the body schema and the body image. The body schema is a largely unconscious
representation of body coordinates in space and help us interact with the
environment (e.g. to grasp a cup). The body image is the conscious
awareness of our body, including aspects of perception (e.g. what you look
like, how your body feels to you from the inside), cognition (what you think about
your body) and emotion (e.g. how positively or negatively inclined you feel
toward your body). This awareness has neural correlates in the brain (e.g. Groves
& Gillmeister, 2016; Coleman & Gillmeister, 2022) and drives behaviours that
people engage in (e.g. less eating, more exercising, concealing their body,
excessive monitoring of their body). Some of these may be defined as health-
related behaviours (eating and exercising) and may be engaged in to augment
the body image. Multiple facets of body image (perceptual, cognitive, emotional,
behavioural) (Grogan, 2016) are affected in mental illnesses characterised by
body image disturbances, such as eating and body dysmorphic disorders.
These disorders are mental illnesses with childhood origins.

ii) These mental representations of our body are (a) foundational for
establishing our sense of self and (b) malleable throughout the course of
life. In the earliest stages of life, infants learn a basic sense of themselves as the
subject of their own experiences (“I am a body”). This basic form of physical self-
awareness is an anchor to higher levels (e.g. sense of agency; understanding
one’s own and other minds; social skills) and is continually re-established through
ongoing sensory-motor experiences (e.g. looking at yourself in the mirror, feeling
your body move). This malleability makes bodily self-awareness vulnerable
to distortions, which may contribute to the disturbed body image seen in
eating and body dysmorphic disorders (e.g. Eshkevari et al., 2012; Provenzano et
al., 2020).

2) There is good evidence from psychological research for a strong reciprocal

relationship between body image and both physical and mental health. It is also
the case that some people are far more vulnerable to these relationships. These
include people with eating and body dysmorphic disorders and those at risk of
developing such disorders: persons who have internalised thin/muscular body ideals,
person who diet and exercise excessively as well as adolescents and young adults who
are more subjected to body image-related pressures and behaviours (e.g. selfies shared
on social media; appearance-related bullying) and whose sense of self and identity is
changing more dramatically.
(3) I will first consider the impact of body image on mental health and vice versa.
Negative body image and body dissatisfaction are associated with low self-esteem and
low mental health (increased depression, anxiety) (e.g. Adams et al., 2017). Low mental
health and negative self-perceptions (“I’m not worthy”, “I’m ugly”) are particularly
prominent in people with eating and body dysmorphic disorders and in those who have
internalised the thin / muscular body ideals prevalent in society and who therefore judge
themselves largely based on their appearance. Research has shown that negative self-
image and negative emotionality are risk factors for dieting and other
unhealthy weight control behaviours and can prospectively predict eating
disorder psychopathologies (Keel & Forney, 2013; Stice et al., 2011). Body image
concerns are higher when one’s self-esteem is contingent on one’s appearance and on
the approval of others (e.g., Overstreet & Quinn, 2012). My own research (Colclough &
Gillmeister, in preparation) has found that appearance-contingent self-esteem is the
strongest predictor of body image concerns in 18-25 year olds and may partly
explain the detrimental effects of social media use on body image (e.g., Saiphoo &
Vahedi, 2019). Persons whose self-esteem is relatively less contingent on appearance
and others’ approval and more contingent on other dimensions of life (e.g. family,
religion/ethics, achievements in other domains) may be more resilient to these effects.

(4) Body image concerns also drive people to make behavioural choices that
impact their physical health (i.e. dieting, exercising). In the case of physical
activity, people’s body image also benefits as a result (e.g. Reel et al., 2007), but
the relationship is less clear for dieting. Body image concerns can also cause physical
ill health by causing unhealthy weight control behaviours (Keel & Forney, 2013;
Stice et al., 2011). One example is Muscle Dysmorphia, a body image disorder related to
excessive (resistance) exercising and dieting (e.g. Cooper et al., 2020). Research in my
lab (Mitchell et al., under review) has found that muscle dysmorphia symptoms
increased mood disturbance due to not being able to exercise as normal during
the Covid-19 lockdown. They also increased social media use and perceived pressure to
“transform” one’s body through exercise while in lockdown. Similar to being prevented
from going to the gym, physical limitations like ill health or physical disabilities
can impact body image by reducing people’s capacity to engage in healthy
behaviours (i.e. eating well, exercising).

 How can the Department of Health and Social Care and its arms’ length
bodies work collaboratively across Government to tackle the health
impacts of a negative perception of body image?

(1) I would urge Government to look at this issue rather broadly. This involves looking
into issues related to

(i) Bullying, internet / social media access and mobile phone use by increasingly
younger age groups. Preliminary research in my lab has found that the upset
caused by appearance-related teasing in 16-25 year olds predicts
greater internalisation of certain body ideals and more body
dissatisfaction, which are known risk factors for body image-related
disorders. Media literacy interventions have shown promise at reducing the
risk for developing body image-related disorders like eating disorders (e.g.
McLean et al., 2017). I would urge more attention to and research funding in
these areas.
(ii) How certain foods are priced to encourage healthier eating choices
(iii) Investing in recreational infrastructure to promote physical and mental health
through improvements in cardiovascular fitness, positive self-care and social
contact.
 (iv) Changing away from an appearance-focused framework to a competence-
focused framework (that is, to look at fitness over fatness) when considering
health impacts.

(2) I do not have the expertise to name specific Government departments for each of
these points but I would advocate appropriate Health and Social Care collaboration with
those concerned in each area.

 To what extent does people’s perception of their body image, and stigma
around particular body images, hinder them from accessing NHS services
and what could be done to address this?

(1) From my perspective, this question may concern both access to eating disorder
services for persons with normal weight and access to services in general for persons
who are overweight. In both cases, body weight or BMI are at the forefront of decisions
about access to services. I have heard of UK cases where persons have been turned
away accessing services that help with eating disorder symptoms because they are a
normal weight (not “thin enough”). I am also aware of UK cases where persons have
been told to lose weight before surgical procedures (to treat other problems) can be
offered by the NHS.

(2) The literature overwhelmingly shows that overweight and obese people are
subject to prejudice from the general public as well as from healthcare
providers (Phelan et al., 2015; Rathbone et al., 2020). There are several reasons for
this, but stigmatisation generally takes the form of blaming the individual for their
weight. This worsens mental health (Phelan et al., 2015; Puhl & Heuer, 2009), reduces
motivation to exercise (Vartanian & Novak, 2011) and, most importantly, does not
achieve the intended outcome of reducing obesity but is instead predictive of
weight gain (Haynes et al., 2018). Stigmatised persons (especially those who feel more
vulnerable because they may suffer from mental health conditions including eating
disorders) are reluctant to access services where there is a chance that their weight
becomes the primary focus, they are made to feel worse about themselves, or turned
down from services as a result of their weight status (e.g. Phelan et al., 2015).

o What training is needed about body image for frontline public

health staff?

(1) Frontline staff could learn about the multiple reasons that cause people to be
overweight (including choice, genetic factors, medication, poor health to name just a
few).

(2) Frontline staff could learn about the complex relationship between stigma, mental
health and obesity, especially within healthcare settings. As stated above, the approach
of focusing on weight in healthcare settings can reduce mental health, increase obesity
and reduce engagement with critical care for other illnesses in overweight persons.
Focus on weight (and the weighing process) in diagnosis or referral can also prevent
normal-weight persons from accessing the help they need for disordered eating. Focus
should instead be on critical behaviours (excessive dieting, binge-eating, purging,
excessive exercising, body surveillance or avoidance) and cognitive-emotional aspects of
body image (body dissatisfaction, shame and self-worth contingent on appearance).

(3) Frontline staff could learn that what matters more for health (morbidity and
mortality) is cardiovascular fitness rather than weight or other aspect of people’s
appearance. Focusing on improving fitness rather than reducing obesity will better
benefit physical (e.g. Davidson et al., 2019) and mental health (e.g. White et al., 2017).
For example, exercise is likely to improve self-esteem contingent on physical
competence (Biddle, 2016). Care should be taken to consider the type and intensity of
physical activity that is promoted to avoid the development of exercise dependence,
excessive exercising and muscle dysmorphia.

(4) It is critical that any learning occurs within a framework that is more weight-neutral
than is currently the case. Interventions to reduce anti-fat attitudes in healthcare
students have been largely unsuccessful and may actually worsen attitudes
(Daníelsdóttir et al., 2010; Meadows et al., 2017). One reason for this may be that
interventions occur within a framework that maintains that fatness is inherently
problematic.

 How can the Government strike the right balance between tackling
obesity in order to help prevent serious diseases, and reducing weight-
based stigma that leads to mental and physical health problems?

(1) It is important to realise that physical and mental health are better served by
assessing cardiovascular fitness and promoting healthy food intake and physical activity
levels than by targeting weight, BMI and the concept of obesity, which focus
unnecessarily on outward appearance rather than on more precise measures of health.

(2) It is well established that physical activity in particular confers protective and
therapeutic benefits for both physical health problems (hypertension, heart disease,
diabetes, cancers) and mental health problems (depression, anxiety, stress, as well as
negative body image). It therefore stands to reason that physical activity to improve
fitness should be at the core of preventing serious disease of any kind.

(3) Approaches that would strike the right balance would be weight-neutral and
encouraging even of small changes and of moderate rather than intense physical activity
(see Biddle, 2016). They would need to be mindful of the fact that excessive exercising,
as well as dieting trends like veganism, may harbour disproportionate numbers of people
at risk of developing muscle dysmorphia and disordered eating (Cooper et al., 2020;
Iguacel et al., 2021; Mitchell et al., under review; Sergentanis et al., 2021). As stated
previously, dieting and other unhealthy weight-control behaviours can predict
psychopathologies like eating disorders.

o How best can public health campaigns tackle negative perceptions

of body image?

(1) Anti-obesity campaigns have not worked well and may have even increased obesity.
Weight stigma and the internalisation of the thin / muscular ideal, which are facilitated
by anti-obesity campaigns, have evidently had multiple negative effects on health and
wellbeing.

(2) Health campaigns may therefore consider changing direction. One approach should
to move away from the focus on appearance and weight. Campaigns could directly target
people’s understanding that feeling bad about one’s body (negative body image) and not
looking after one’s body (low physical health and fitness) are at the root of mental and
physical ill health. A good health campaign would be weight-neutral but promote positive
self-care and cardiovascular fitness. In doing so, it could also try to encourage sources of
self-esteem that are contingent on physical or academic competencies or on family,
other social support networks and citizenship (that is, not contingent on appearance).

 To what extent are people who have a negative body image drawn to
cosmetic procedures, and how do cosmetic procedures affect their body
image?
(1) People are drawn to such procedures because they are increasingly acceptable,
accessible and safe. An improvement in body image is desired from them in the same
way as more harmless procedures like hairdressing. It is important to distinguish
temporary procedures (e.g. lip fillers), minor procedures (e.g. piercings) and more
extreme surgical procedures (e.g. “nose jobs”, breast augmentation, liposuction).

(2) There are some suggestions that minor procedures may be protective of body image
(Claes et al., 2005; Coleman & Gillmeister, 2022; Kluger et al., 2019). People who have
such procedures are no worse than those without in terms of their body image (Coleman
& Gillmeister, 2022), self-esteem (Hong & Lee, 2017) and mental health history (Giles-
Gorniak et al., 2015). Claes et al. (2005) even found that female eating disordered
patients with piercings report less severe eating disorder symptoms than those without
piercings. Body image-related reasons (desire for body ornamentation or embellishment,
increased physical or sexual attractiveness) are listed among the reported motivations
for piercings in general, and dominate motivations in women in particular (e.g., Kluger et
al., 2019; Coleman & Gillmeister, 2022). Navel piercings, for example, which embellish
an area of the body women often feel negatively about (e.g. Jansen et al., 2005), were
found to improve body image in women’s retrospective reports (Coleman & Gillmeister,
2022). Facial fillers were also found to temporarily enhance body image (Sobanko et al.,
2018). It can be argued that such procedures not just enhance body image but are
expressions of body care that confer protection against self-harming behaviours in those
at risk of such behaviours (Claes et al., 2005; Möller et al., 2018; Stirn & Hinz, 2008).

(3) The desire for dermatological and more extreme surgical procedures is a well-known
dimension of disorders characterised by body image disturbances (eating disorders and
body dysmorphic disorders) (Littleton et al., 2005; Mancuso et al., 2010). The majority
of body dysmorphic patients desire procedures (71-76%) and most also receive them
(Crerand et al., 2005; Phillips et al., 2001). While patients expect otherwise, evidence
shows that procedures rarely improve body image, however, probably because the
underlying insecurities are not addressed. Instead, patients merely reorient to other
perceived bodily deficiencies with no change in dysmorphic concerns (Crerand et al.,
2005; Phillips et al., 2001).

 Is there sufficient support and advice for people who are considering
cosmetic procedures?

(1) The literature has called for body dysmorphia screening when people apply for
surgical procedures and to refer those at risk to more appropriate psychological or
psychiatric services (e.g., Crerand et al., 2005; Mancuso et al., 2010). Providers of
cosmetic surgery procedures are ideally placed to provide such information and facilitate
referrals for people seeking cosmetic procedures who might better benefit from
psychological treatment for body dysmorphia instead.

 What form should a regulatory regime for non-surgical cosmetic

procedures take in order to improve patient safety?

I am not responding to this point.

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